Atrial Fib. Noninvasive Treatment

Specialties CCU

Published

Hi Everyone Just Wondering What Are Some Non Invasive Treatments For A. Fib.?

Hey guys this is my first post...

This is what the AHA says about A-fib and A-flutter (they both have the EXACT same treatment / algorithm)

The first question that must be asked after identification of AF/AF (or any tach, wide or narrow except the automatic tachs MAT,JT,ST ) is:

Question #1 "Is the patient stable or unstable".

You must remember these general rules:

Stable = drugs (we have a little time)

Unstable = immediate synchronized cardioversion for all patients except the automatic tachycardias (MAT, JT, ST).

This is an absolute rule because we have no time! Every minute we wait leads to organ hypo-perfusion that leads to MOF (multi organ failure) which has a 40-80% mortality rate.

American heart feels that afib > 48 hours = left atrial clots.

If someone has afib for less than 48 hour you may convert the rhythm (chemically or electrically, both are acceptable) immediately because we dont have the fear of left atrial clots.

The AHA guidelines for stable AF = Anticoagulate, control the rate and convert the rhythm.

Stable afib for > 48 hours we must:

*Begin anticoagulation (for 3 weeks) because of high probability of left atrial clots.

* Control the rate if afib out of control (greater that 100 usually >120 +++)

Remember the faster the heart rate the less efficient it becomes. Calcium channel blockers, beta blockers or dig are acceptable. Diltiazem is the preferred drug over verapamil (it has a less negative inotropic affect) Beta blockers are also acceptable. Do not give amiodarone because it might control the rate but might inadvertently convert the rhythm (it can do both). Dig takes the longest to control the pt. We don't use poly drugs / multi antiarrhythmics. It causes arrythmias.

* Convert the rhythm: After 3 weeks of anticoagulation bring the pt into the hospital, perform a TEE (trans-esophageal echocardiogram, which is about 95% accurate for ruling left atrial clots). If there are no clots you may convert the rhythm. Post cardioversion care, is to place the pt on anticoagulants for an additional 4 weeks.

* This is called delayed cardioversion

Some MDs have a problem leaving there pt in new onset afib for three weeks while we antiacoag our patient. Remember, the longer the patient remains in afib, it might become their permanent rhythm. Some MD's, if it's close to the 48 hour window, will perform a TEE in the ER and if no atrial clots will cardiovert the pt immediately and then send them home on 4 weeks of anticoagulation. This is called early cardioversion.

For unstable afib or any unstable tachs, wide or narrow except the automatic tachs (MAT, JT, and ST) we use immediate cardioversion. Period.

Remember what unstable means and looks like. Are there signs of shock or hypo-perfusion? Is the patient hypotensive, cold and clammy with mottled color and thready pulses? Are there crackles halfway up the lungs? Does the pt have chest pain or SOB or ALOC? These common signs scream severe life threatening shock. We have to act fast. Someone's mom or dad is begging us "please save me"!

Unfortunately, many clinicians allow their pt to remain hypotensive for a prolonged time while other things or tests are done. If someone is hypotensive and symptomatic, we must act quickly! Every minute of hypotension leads the patient towards multi organ failure (MOF).

MOF has the highest mortality rates of almost all ICU admissions (40-80% depending on how many organ systems are injured).

Think about what a single prolonged (or not) hypotensive insult to the organs will do. Would the organs be injured from cellular hypoxia? Yes. What happens when we injure something? It becomes swollen and edematous by the hour.

Question: Why are the organs injured?

Answer: From cellular hypoxia. Imagine if you punched a brick wall and broke your hand in multiple places. Would it become swollen? Of course. Could you use your swollen and injured hand well? No, your hand would not function well.

Now, picture the swollen and heavy kidneys that gradually stop producing urine because their so badly injured by cellular hypoxia. So what's the treatment? Cautious fluids, diuresis or dialysis, dopamine etc... This is the beginning of MOF.

(organ system dysfunction #1)

The lungs also become swollen and heavy and stop oxygenating and ventilating well so we have to increase Fio2 and Peep and ventilatory support.

(organ system dysfunction # 2)

The gut dies and becomes necrotic = dead bowel + surgery

(organ system dysfunction # 3)

Etc... You get the point.

Question: Why do we use IMMEDIATE synchronized cardioversion for all unstable tachs (except the automatic tachs MAT, JT)?

Answer: Cardioversion is the definitive treatment for unstable tach. We do use concurrent administration of anti-arrhythmics. We ensure effective oxygenation (generally NRB) while preparing for immediate synchronized cardioversion with 50-100-200-300-360 joules in a step wise approach. Some docs start at 50j, some at 200j or higher. We don't sedate or wait for an IV it just wastes precious time. We immediately cardiovert.

Question: If our pt was unstable, had all the classic signs of hypoperfusion but had afib for > 48 hours ( a high likely hood of atrial clots) would we use immediate cardioversion ?

Answer: Yes, what other option do we have. If we don't convert the rhythm the patient will die form cellular hypoxia > MOF. We have to cardiovert immediately. If the patient did throw a embolic stroke we would use fibrinolytics. Were picking the lesser of two evils on that one. Hope this helps...

Jeff RCP

Anaheim CA

Up Vote Up Vote ×
Specializes in CCU/CVU/ICU.
Hey guys this is my first post...

This is what the AHA says about A-fib and A-flutter (they both have the EXACT same treatment / algorithm)

The first question that must be asked after identification of AF/AF (or any tach, wide or narrow except the automatic tachs MAT,JT,ST ) is:

Question #1 "Is the patient stable or unstable".

You must remember these general rules:

Stable = drugs (we have a little time)

Unstable = immediate synchronized cardioversion for all patients except the automatic tachycardias (MAT, JT, ST).

This is an absolute rule because we have no time! Every minute we wait leads to organ hypo-perfusion that leads to MOF (multi organ failure) which has a 40-80% mortality rate.

American heart feels that afib > 48 hours = left atrial clots.

If someone has afib for less than 48 hour you may convert the rhythm (chemically or electrically, both are acceptable) immediately because we dont have the fear of left atrial clots.

The AHA guidelines for stable AF = Anticoagulate, control the rate and convert the rhythm.

Stable afib for > 48 hours we must:

*Begin anticoagulation (for 3 weeks) because of high probability of left atrial clots.

* Control the rate if afib out of control (greater that 100 usually >120 +++)

Remember the faster the heart rate the less efficient it becomes. Calcium channel blockers, beta blockers or dig are acceptable. Diltiazem is the preferred drug over verapamil (it has a less negative inotropic affect) Beta blockers are also acceptable. Do not give amiodarone because it might control the rate but might inadvertently convert the rhythm (it can do both). Dig takes the longest to control the pt. We don't use poly drugs / multi antiarrhythmics. It causes arrythmias.

* Convert the rhythm: After 3 weeks of anticoagulation bring the pt into the hospital, perform a TEE (trans-esophageal echocardiogram, which is about 95% accurate for ruling left atrial clots). If there are no clots you may convert the rhythm. Post cardioversion care, is to place the pt on anticoagulants for an additional 4 weeks.

* This is called delayed cardioversion

Some MDs have a problem leaving there pt in new onset afib for three weeks while we antiacoag our patient. Remember, the longer the patient remains in afib, it might become their permanent rhythm. Some MD's, if it's close to the 48 hour window, will perform a TEE in the ER and if no atrial clots will cardiovert the pt immediately and then send them home on 4 weeks of anticoagulation. This is called early cardioversion.

For unstable afib or any unstable tachs, wide or narrow except the automatic tachs (MAT, JT, and ST) we use immediate cardioversion. Period.

Remember what unstable means and looks like. Are there signs of shock or hypo-perfusion? Is the patient hypotensive, cold and clammy with mottled color and thready pulses? Are there crackles halfway up the lungs? Does the pt have chest pain or SOB or ALOC? These common signs scream severe life threatening shock. We have to act fast. Someone's mom or dad is begging us "please save me"!

Unfortunately, many clinicians allow their pt to remain hypotensive for a prolonged time while other things or tests are done. If someone is hypotensive and symptomatic, we must act quickly! Every minute of hypotension leads the patient towards multi organ failure (MOF).

MOF has the highest mortality rates of almost all ICU admissions (40-80% depending on how many organ systems are injured).

Think about what a single prolonged (or not) hypotensive insult to the organs will do. Would the organs be injured from cellular hypoxia? Yes. What happens when we injure something? It becomes swollen and edematous by the hour.

Question: Why are the organs injured?

Answer: From cellular hypoxia. Imagine if you punched a brick wall and broke your hand in multiple places. Would it become swollen? Of course. Could you use your swollen and injured hand well? No, your hand would not function well.

Now, picture the swollen and heavy kidneys that gradually stop producing urine because their so badly injured by cellular hypoxia. So what's the treatment? Cautious fluids, diuresis or dialysis, dopamine etc... This is the beginning of MOF.

(organ system dysfunction #1)

The lungs also become swollen and heavy and stop oxygenating and ventilating well so we have to increase Fio2 and Peep and ventilatory support.

(organ system dysfunction # 2)

The gut dies and becomes necrotic = dead bowel + surgery

(organ system dysfunction # 3)

Etc... You get the point.

Question: Why do we use IMMEDIATE synchronized cardioversion for all unstable tachs (except the automatic tachs MAT, JT)?

Answer: Cardioversion is the definitive treatment for unstable tach. We do use concurrent administration of anti-arrhythmics. We ensure effective oxygenation (generally NRB) while preparing for immediate synchronized cardioversion with 50-100-200-300-360 joules in a step wise approach. Some docs start at 50j, some at 200j or higher. We don't sedate or wait for an IV it just wastes precious time. We immediately cardiovert.

Question: If our pt was unstable, had all the classic signs of hypoperfusion but had afib for > 48 hours ( a high likely hood of atrial clots) would we use immediate cardioversion ?

Answer: Yes, what other option do we have. If we don't convert the rhythm the patient will die form cellular hypoxia > MOF. We have to cardiovert immediately. If the patient did throw a embolic stroke we would use fibrinolytics. Were picking the lesser of two evils on that one. Hope this helps...

Jeff RCP

Anaheim CA

dont think the OP wanted a regurgitation of ACLS algorhythms and such.

And i didnt quite get the gist of your post...can you repeat it?

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Hi Dinith and thanks for the post.

First lets understand one basic thing. The AHA algorythms are community standards and we should be using it on most patients. This is not to say we can't deviate from AHA guidelines and try a new technique or drug if we have sound scientific evidence that shows the new technique or drug is as or more effecitive than the "standard". Bottom line. You should be using the ACLS protocols for all afib patients as a community standard. Im sure you get the gist : ) Have a great day...

"Anybody know if there's a logarithm or protocol for Acute A-Fib that Dr's learn or count on?

Papaw John"

That was the question I was answering : )

Jeff RCP

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Specializes in LDRP.

I have post op cabg pt's on my unit. They are all on PO amio, and nasal bactroban as a preventative to afib.

Of course, there are always a few (who don't have a hx of afib) who go into afib anyways.

A cardizem bolus/drip usually takes care of that problem.

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Specializes in CCU/CVU/ICU.
and nasal bactroban as a preventative to afib.

.

??

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Specializes in LDRP.

I have no idea how or why it works, or even if it does, but we do it.

Starts the night before surgery, and then twice a day for 5 days afterwards.

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Hey happy nurse,

Very interesting. Is that all preop cabg patients? Could you kindly ask the doc on the specifics off why you use nasal bactroban for afib? I would love to learn a new technique. See if he can give you info on the study/author/journal that he used to rationalize his choice. I have looked online but could not find anything. Thanks,

Jeff

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Specializes in Education, FP, LNC, Forensics, ED, OB.

Just received a link from eMedicine about atrial fib. You might need to sign up in order to read. It is free:

http://www.emedicine.com/rc/rc/pfeatured/i15/atrial.htm

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Just received a link from eMedicine about atrial fib. You might need to sign up in order to read. It is free:

http://www.emedicine.com/rc/rc/pfeatured/i15/atrial.htm

Hey, thanks for that link.....it's seems quite good.

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